Requesting an eAgreement: from prescription to response

You request an eAgreement through your practice software. You check the prescription and existing approvals, send the necessary data to the health insurance fund (mutualité) and follow up on the response. Sometimes you get a decision straight away; sometimes the fund's medical adviser first asks for more information. So your request is only complete once you have read the response and know what it means for the treatment.

What do you prepare before your request?

eAgreement handles both notifications and approval requests. Registering a routine treatment is therefore not the same as a request for a serious condition. Choose the type that fits your patient's situation. Our overview of eAttest, eFact and eAgreement shows where this step fits in.

First open the list of decisions. According to the NIC, you can consult it for a patient with whom you have a therapeutic relationship. Check whether a suitable approval or a pending request already exists. That way you avoid submitting the same case twice.

• Patient details. Compare the name and INSZ (NISS) with the patient record. Also check insurability through Member Data for the relevant period.
• Prescription. Check the patient and prescriber, the prescriber's RIZIV-INAMI number (RIZIV-INAMI being the Belgian health insurance institute), the date, signature, maximum number of sessions and diagnostic details. Also look at the location of the injuries if it is not clear from the diagnosis, and at any different start date. Depending on the condition, additional details are required.
• Legible copy. Open the scan before you attach it. Is the full text on it, including the back? For a paper prescription, you attach an electronic copy and keep the original.
• Supporting evidence. Gather the reports and examinations that belong with this type of request. A prescription alone is not enough for every case.

Let's follow a fictional example. Your patient has a condition on the E list, but no suitable approval yet. You prepare the case together with the doctor. For a first E request, this includes a diagnosis confirmed by a specialist, with an explanation of the limitations, the need for long-term treatment and the treatment plan. Which additional examinations are required depends on the condition.

How do you send the request?

1. Open the right patient record. Go to the eAgreement function in your software. Button and screen names differ from one package to another.
2. Choose the appropriate action. Is it a new request, an extension or an addition to an existing approval? A new prescription does not automatically mean you need to request an entirely new approval.
3. Fill in the requested details. Check the pathology category, the dates and the prescriber's details. Attach the prescription and the required documents. Read through the summary one last time.
4. Send and check the response. Make sure you can find the sent request, attachments and the reference received in the patient record. Clicking Send does not yet tell you whether the request has been processed.

If you cannot log in or send, check your eHealth certificate and the eHealth status dashboard. If the connection dropped, first check whether the request arrived anyway. If that remains unclear, give your software supplier the error message, the time and the reference.

What does the response you receive mean?

Some requests get a final response within a few seconds. Others go to the medical adviser. In our E example, a message first appears saying the case is under review. Agree within your practice on who follows up on such requests, including when the requesting physiotherapist is away.

The table describes what the responses mean. Your software may use different labels.

Keep the original response as well. Consulting the list of decisions does not show all rejections, refusals and cancellations. A request that is not listed there has therefore not necessarily never been submitted.

How do you provide additional information?

In our example, the medical adviser asks you to describe the functional limitations in more detail. Read the full question and any deadline. Note which report is missing and who will provide it. Where necessary, align the content with the treating doctor.

Open the original request and use the function to substantiate it. This is done by the physio who submitted the request, after an explicit request for information from the health insurance fund. Add the requested explanation or attachment and check the response to that addition.

This way you keep everything in one case. Note what you sent and when. A colleague who takes over the follow-up can then see immediately whether you are still waiting for a report or already for a new decision.

What if the question is addressed to the prescriber?

Then the health insurance fund expects the answer from the prescriber. You do not need to answer that question through the substantiation function. You can, however, liaise with the doctor if the request is stuck, and explain to your patient what is still pending. Do not fill in medical information yourself based on assumptions.

What do you check in the final decision?

After the additional information, our fictional case receives an approval. Compare the patient, approval type, reference, start date and any end date with your request. Also look at any restrictions or conditions. The date you receive the response is not necessarily the start date of the approval.

Discuss with your patient what the decision means for reimbursement. Before billing, also check the prescription, insurability and the conditions for the sessions you are charging. Keep the decision with the patient record and, if needed, set a reminder before the end date.

If the request is refused, read the reasoning first. Is something missing that you can correct, or does the situation not meet the conditions? Ask the health insurance fund for clarification if the reason is unclear. Resending the same request unchanged will not get you any further.

How long do you wait for a response?

An automatic response and an assessment by the medical adviser follow different paths. So do not assume a fixed response time for all cases. The 14-day rule that exists for certain requests for additional services does not automatically apply to every eAgreement request.

Schedule a fixed moment to review open cases. First check the messages received and the current status. If there is an unexplained delay, contact the health insurance fund with the request reference at hand.

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